The outcomes that matter most

Outcomes reported to the committee in this evidence review included whether the initial health assessment took place, completion of routine health assessments, timely completion of health assessments, and quality of the completion of health records. Other outcomes referred to the follow up after completion of health records i.e. rate of detection of social-emotional or health problems, number recommended services who actually received them, and number referred to hospital services who did not attend. In addition, some qualitative evidence was presented regarding themes relating to the acceptability, barriers, and facilitators to the success of a medical clinic co-residing with an agency providing services to looked after children and young people. The committee were particularly interested in the outcomes regarding completion and follow up of assessments, and identification of need. However, it was noted that some studies were unclear in how they had defined these outcomes (e.g. Hardy 2015, Horwitz 2000, and Jee 2010). For example, Horwitz 2000 reported number of “problems” identified but it was unclear what measures and thresholds were used to define these. Another problematic example was a study by Jee et al. which compared rates of detection of social-emotional problems for children five and younger, however, it was unclear how detection of social-emotional problems was defined, and, indeed, the classification of these may have differed between comparison groups. The committee took this uncertainty into account when making recommendations.

As in previous reviews, the committee were primarily interested in objective findings, such as those derived from medical records and with clear definitions e.g. whether the screening of a looked after child took place, whether referrals for a health assessment had been received, number of “did not attends”, number of referrals for a medical problem following assessment, number registered with a dentist, number with complete BAAF books, whether assessment took place within a set time period (14 days in one study). While the reported qualitative outcomes were considered helpful, these were highly time and context dependent for their relevance to the UK population of looked after children and young people.

The quality of the evidence

The committee considered the overall quality of the evidence presented. There was no randomised controlled trial evidence presented meaning that there may be important differences between comparison groups. Some studies used interrupted time series-type study designs or uncontrolled before and after studies, meaning comparison groups were not selected in a prospective design. Studies did not always fully report baseline characteristics, making it difficult to assess for this risk of bias. In addition, the amount of missing data was also commonly not reported. As described above, some studies were unclear in how they measured their outcomes. The committee noted that the control groups were also frequently poorly defined, this made interpretation difficult. To be able to assess the external validity of a study’s findings, the committee needed to make a judgement call regarding whether the standard of care in the control arm was comparable to standard practice in the UK. In many studies this was unlikely to be the case, particularly when the study was based in a different social context such as the USA or Canada and particularly when the cohort was recruited many years ago. For example, care planning has developed and improved considerably in the UK since 2010.

As described above, context was particularly important in interpreting the findings of the qualitative study looking at the acceptability, barriers, and facilitators to the success of a medical clinic co-residing with an agency providing services to looked after children and young people (Swanson 2016). The committee noted that this study was based in Canada, and that it was unclear how comparable their social care context was. In addition, the strength of qualitative findings was hampered by the fact that there was only one study identified. The study authors recognised that their recruitment strategy may have been a limitation, as they did not actively seek out participants who may have more negative views of the clinic, and that participants agreeing to participate may have been those with more positive views, leading to possible selection bias.

Benefits and harms

Evidence from eight studies was presented to the committee, this included results from four interrupted time series, two non-randomised controlled studies, one uncontrolled before and after study, and one qualitative study.

The committee considered evidence from one interrupted time series from the USA showing that the introduction of a centralised screening programme (relying on screeners specifically employed and trained for this purpose who delivered an in-home assessment within 45 days of entry into care). This was compared to a previous system whereby caregivers were required to bring their children to specific locations for screening. The committee noted that this study was from 2008 and based in the USA. They also considered that the standard of care described was poorer than that currently received in the UK where a child receives a statutory initial health assessment within 20 working days from entry into care. This includes an assessment of the effect of the child’s health history on his or her development, and screening for defects of hearing or vision (see Promoting the health and well-being of looked-after children Statutory guidance for local authorities, clinical commissioning groups and NHS England, 2015). Rather than being carried out by employed screeners, UK law requires that a registered medical practitioner carry out this initial assessment.

Next the committee considered evidence from a UK-based interrupted time series looking at the “change project”. This was a project introduced to support statutory health assessments for LACYP. This study used a named nurse as a “change agent” to support multiagency working to improve statutory health assessments for LACYP. The activities of this named nurse included, identifying key stakeholders, attending social care team meetings, facilitating the passage of information between stakeholders using an email system, and a three-monthly service review meeting in which information was shared between providers and any concerns about the children raised and solutions discussed. In addition, assessment paperwork was streamlined, clear guidelines developed, and a new system of prompts for helping social workers achieve more timely assessments was established. These changes resulted in improvements in number of referrals received among those due a health assessment, and a reduction in the number of “did not attends” for hospital appointments. However, the committee noted that the study was old and had occurred prior to care review and assessment reforms since 2010. The group did not want to be prescriptive with regard to making specific recommendations for email systems or prompts for social workers, since these may not be applicable or helpful in all cases. However, the principle of facilitated multiagency working was considered to be important, since this is the means by which systems can adapt to cope with local challenges. Particularly, the committee were interested in the use of regular meetings, or forums, for care providers to facilitate the exchange of information and to provide the opportunity to adapt care systems to meet the needs of looked after children. This was considered important not just for health assessments but for broader care issues such as the need to upskill in response to the needs of unaccompanied asylum seekers. Therefore, the committee recommended that local authorities consider establishing a forum to facilitate communication and bring together expertise from different agencies in the network of care providers for looked after children. Additionally, this research paper measured the success of the project using two 3-month audits, one before and one after the implementation of the Change Project. Likewise, the committee recommended that health care professionals responsible for the care of LACYP should audit the uptake of health action plans to ensure service provision (and any adaptions of service provision to meet the need of LACYP) improves the outcomes of children in their care. The committee noted that these audits should have multidisciplinary input, something that would be facilitated by the use of multiagency forums.

The committee considered a UK-based interrupted-time-series looking at the use of enhanced mental health screening for early intervention in looked-after children entering care before 5 years of age. This study introduced a more in-depth interview with foster carers (expanding on the use of the ages and stages questionnaire and social emotional growth chart). This extra information was discussed with the paediatrician after the initial health assessment (IHA), then all the information from the IHA (screening questionnaires, observations, developmental and health information) and background information was integrated into a summary compiled by a Child and Adolescent Mental Health Services (CAMHS) clinical specialist which included recommendations for a child’s social and emotional development. The committee noted that this service resulted in greater number of children identified as having difficulties (compared to the prior 12 months). This was a UK-based study which described a level of assessment greater than that currently used in practice (including involvement of CAMHS, for instance). The committee were in consensus that current initial health assessments were often insufficiently detailed to pick up mental health needs to allow for early mental health provision for looked after children entering care, and that effort should be made to ensure children entering care, who needed it, had had their mental and emotional health needs assessed in full. Recognising the reality that such an assessment can’t be squeezed into the initial health assessment, the committee recommended that after the initial health assessment for looked-after children and young people, practitioners should consider the need for an additional specialist mental and emotional health assessment, particularly for babies and children, once the looked-after person has begun to form a relationship with the primary caregiver. The committee noted that mental health problems are commonly overlooked in young children and babies in whom mental health symptoms may be less obvious.

This study also included a compilation and summarising of health records as a key component of the intervention. The committee discussed the importance of having health records that are neatly compiled, highlighting and summarising key events, and giving a sense of a timeline of care for the looked after person. It was noted that work to compile records is something that is done inconsistently across local authorities. Therefore, a recommendation was made to create a chronological summary and compilation of health records to give a clear sense of the looked after child’s past, present, and future health needs. By consensus, the committee considered that this simple intervention had the potential to be transformative for the care of looked after children by facilitating the passage of information between agencies and preventing important needs and health plans from becoming lost.

By consensus the committee also considered the importance of gaining a full health record/health history from the birth parents to create a complete record of the looked-after child’s health. However, it was noted that gaining consent for this may be a difficult or lengthy process. Therefore, the committee discussed the importance of attempting to gain this consent as soon as possible in the care process in order to prevent missing important health information that could be important for directing the plan of care. The committee recommended for all children and young people, on entry into care, to engage birth parents to gain consent to retrieve information about birth parent’s health, and child’s birth records for inclusion in health records.

Next the committee considered a non-randomised controlled trial from the USA which used a foster-care-specialist multidisciplinary clinic to provide complete medical examination, developmental assessment, psychological assessment, speech and language assessment, and motor evaluation compared to community providers administering the same tests. This study found that the specialist clinic identified more developmental and mental health problems and referred more children for follow up services. However, once again, the study was old (participants were recruited between 1992 and 1993) and from the USA, therefore the committee were unable to decipher how comparable the standard of care was in the control group to that of current UK practice.

Another qualitative study was presented which also considered the co-location of a multidisciplinary medical clinic sharing space with a non-profit agency to provide a more tailored experience for looked after children and young people. The committee noted that the study gained the opinions of foster carers only, rather than the looked after children themselves. Overall, the committee considered this to be a harmful intervention since it segregated looked after children from the rest of society. A lay member mentioned that there are already sufficient services to create a common space for looked after children and young people and that to do so for the purpose of medical examination is unnecessary and merely perpetuates the sense that children and youth in care are different from others. However, one of the themes drawn out from this study involved an appreciation of the continuity of medical professionals in the care of LACYP (“there are so many variables in this child’s life that to have one thing that is continuous is wonderful”), the committee agreed with this, and considered the importance a medical professional who is familiar with the looked after child, and their medical and social history, to perform routine health assessments. This is important both to promote a trusting (and medically adherent) relationship between the child and the medical practitioner, but also to help the practitioner to spot important changes in the health needs of the child to support better care. Therefore, the committee recommended that continuity of medical professionals in completing routine health assessments for looked after children should be promoted.

Next the committee considered evidence from a USA non-randomised controlled study which considered the establishment of a work group composed of personnel from child welfare, medical, and dental services. The work group aimed to establish a service providing a complete health assessment within 14 days of entry into foster care including a standardised assessment using common checklists across the two treatment counties. The committee noted the positive outcomes from this older (2007) study, which included improvements in the completion of health records over a year and an increase in the speed of health assessments (more examined within 14 days). The committee considered that this USA study was setting up a service similar to that which exists in UK practice. The timescale employed in this study was considered aspirational but also comparable to the speed of health assessments in UK-practice (20 working days).

The committee then considered evidence from a UK-based study that considered the use of a specialist nursing service in residential care for promoting the completion of health assessments, for liaising with health professionals and social care providers to ensure the health needs of children were being met, and for ensuring standard health recommendations were being adhered to. The committee noted that this intervention resulted in improvements in the number of children with up to date and complete BAAF health record booklets, number with complete immunisations, and number registered with a dentist. However, the committee noted the age of the study was a problem, recruitment having occurred between 2006-2007. The committee considered that the improvements in statutory-level care review and assessments meant that it was unclear whether intervention described would still be as effective relative to standard care today. The intervention was also considered to have resource implications since not all residential care units could employ a full-time specialist nurse. In any case, the committee considered that one of the key components of this intervention was to improve communication between disciplines to facilitate multiagency working between health professionals, social care providers, and residential care home staff. And to ensure that statutory guidance was being adhered to. As such, the recommendation previously made regarding the use of multiagency forums and audits was applicable.

Finally, the committee also heard expert testimony evidence (see Appendix M) on the journey and care of unaccompanied asylum seekers by two experts: Alex Stringer (AS), a Service Manager for UASC in Kent and Ann Lorek, a Doctor for Child Protection in Lambeth. These testimonies touched on many aspects of the health needs of LACYP from arrival in the UK to leaving care, see Appendix M. Expert testimony highlighted specific and prevalent health needs of unaccompanied asylum seekers compared to the broader population of looked after children and young people in the UK. These include: nutritional deficiencies, including vitamin D deficiency, issues of adjusting to the UK diet, and gastrointestinal symptoms; oral health and dentition problems as a result of not having had access to UK routine dental care; infectious diseases such as TB, and blood borne infections such as HIV and hepatitis; sensory and developmental health problems as a result of lack of previous screening for example, hearing, vision, and mobility problems; mental health problems, particularly trauma; sexual health issues, including sexually transmitted diseases; problems relating to previous assault and abuse, and including abuse linked to faith and culture (for example, FGM and breast flattening); unaccompanied asylum seekers were frequently found to have problems acclimatising to a regular sleep schedule as a result of travelling long distances, often with continuously disturbed sleep; finally, the material needs of unaccompanied asylum seekers was found to be important since many unaccompanied asylum seekers may arrive with very few possessions. Accordingly, the committee recommended tailored initial health assessments which should address the additional risks posed to unaccompanied asylum seekers, listed above, as a result of their country of origin and journey to the UK. These assessments should also address difficulties in communication due to language barriers with provision of an in-person translator – particularly for the initial health assessment.